REMOTE - Program Integrity Clinical Reviewer II (Readmission experience preferred) - R12728

Job SummaryThe Program Integrity Clinical Reviewer II contributes to the investigative process by evaluating medical records, looking for correct documentation, trends, patterns, missing information, upcoding, unbundling, etc. in relation to clinical documentation, medical standards, and CPT, HCPCS and ICD-10 codes, with an emphasis on readmission.Essential FunctionsConduct claim reviews against medical records to determine claim accuracy for claims payment. This will support prepayment, post-payment, and SIU teams.Conduct meetings to present identified clinical issues and associated research to Medical Directors and physician experts for validationConduct, participate or contribute to on-site audits and investigations of medical professionals, subcontractors and contracted entitiesAssist the audit and investigative teams in the development of clinical and coding based audit toolsDraft proposed provider education and formal corrective action plans for clinical and coding deficienciesProvide SIU perspective to the development of clinical and payment policies and the Utilization Management CommitteeCollaborate with other departments including, but not limited to Pharmacy, Medical Management, Provider Relations, Claims, Contracting, Case Management, and LegalResponsible for maintaining confidentiality of all sensitive investigative informationDevelop and maintain SIU specific clinical and investigative training materials to include processes (SOPs)Create and execute monthly audits of investigative staff’s work to ensure processes are followed and to identify additional training opportunitiesCreate, use and/or provide multiple training mediums such as presentations, quick reference tools, speakers, internet and state and federal resources, etc.Perform any other job related instructions as requestedEducation And ExperienceBachelor of Science Degree equivalent experience years of relevant experience is requiredMinimum of five (5) years clinical practice experience requiredSignificant experience auditing medical records against claims is requiredPrior Fraud, Waste, Abuse (FWA) investigation and auditing experience preferredMedical research experience is preferredCompetencies, Knowledge And SkillsCPT, HCPCS and ICD-10 coding knowledge is requiredKnowledge of Medicare/Medicaid/Managed Care preferredProficient with Microsoft Office Word, Excel and PowerPointStrong organizational and time management skillsBroad-based clinical and medical coding knowledgeStrong analytical skills with high attention to detailsSkill in negotiating issues and resolving problemsHigh-level Investigative experienceTraining/teaching experience and demonstrated knowledge of adult learning environmentExcellent written and verbal communication skills with adeptness to create, present and evaluate present department, role-focused teaching materials across topicsAbility to communicate verbally and in written form with a variety of levels within the organizationCritical decision making/problem solving skillsConsiderable skill set in planning and project managementAbility to work independently and within a team environmentMedical research background preferredLicensure And CertificationCurrent, unrestricted RN licensure in state of practice is requiredCertified Medical Coder (CPC, RHIT or RHIA) is required at time of hire or within 18 months of hire dateWorking ConditionsGeneral office environment; may be required to sit or stand for extended periods of timeCompensation Range$72,200.00 - $115,500.00 CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.Compensation TypeSalaryCompetencies Fostering a Collaborative Workplace Culture - Cultivate Partnerships - Develop Self and Others - Drive Execution - Influence Others - Pursue Personal Excellence - Understand the BusinessThis job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.